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Upper extremity fragility fractures. Shoji, M. M., Ingall, E. M., & Rozental, T. D. (2020) Level of Evidence : 5 Follow recommendation : 👍 👍 Type of study : Preventative Topic : Fragility fractures - Prevention of secondary osteoporotic fractures This is a narrative review on screening and prevention of fragility fractures in patients presenting with a distal radius fracture (DRF). Fragility fractures are defined as fractures associated with low energy trauma. Interestingly, older clients presenting with a DRF, are 5 times more likely to have a fragility fracture within one year compared to their peers. The presence of a DRF in people older than 50 can suggest the presence of bone weakness (osteopenia or osteoporosis) and a Bone Mass Density (BMD) assessment is therefore indicated in these clients. A BMD assessment can be combined with the Fracture Risk Assessment Tool ( FRAX ) to provide a 10 years risk of hip fracture or other osteoporotic type fractures. If the results of the FRAX suggest that there is ≥ 3% risk of hip fracture or ≥ 20% risk of osteoporotic fractures in patients older than 50, bisphosphonate therapy should be initiated. In addition, a balance and strength training exercise program should be started. Clinical Take Home Message : Hand therapists have a great opportunity to reduce the risk of fragility fractures among their clients by screening them through tools such as the FRAX . Hand therapists may also refer their clients with a distal radius fracture, who are older than 50, to their GP suggesting a bone mass density assessment. Hand therapist can also assess lower limb strength and balance in people with distal radius fracture through simple tests such as the Chair Stand Test and the Timed up and Go test. Recently, an mobile app called Nymbl has been sponsored by ACC and can be used by our older clients to keep active and reduce their risk of falls. If clients are provided with medications such as bisphosphonate, hand therapists should encourage them to take them as prescribed and provide educational resources on osteoporosis (e.g. NIH , NOF , IOF ). For further information on our key role in fragility fracture screening, see this synopsis . URL : https://www.jhandsurg.org/article/S0363-5023(20)30407-X/fulltext Available through the Journal of Hand Surgery (American volume) for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract The population of elderly patients is rapidly increasing in the United States and worldwide, leading to an increased prevalence of osteoporosis and a concurrent rise in fragility fractures. Fragility fractures are defined as fractures involving a low-energy mechanism, such as a fall from a standing height or less, and have been associated with a significant increase in the risk of a future fragility fracture. Distal radius fractures in the elderly often present earlier than hip and vertebral fractures and frequently involve underlying abnormalities in bone mass and microarchitecture. This affords a unique opportunity for upper extremity surgeons to aid in the diagnosis and treatment of osteoporosis and the prevention of secondary fractures. This review aims to outline current recommendations for orthopedic surgeons in the evaluation and treatment of upper extremity fragility fractures.

Management of radial tunnel syndrome: A therapist's clinical perspective. Cleary, C. K. (2006) Level of Evidence : 5 Follow recommendation : 👍 Type of study : Therapeutic Topic : Posterior interosseous nerve entrapment - Conservative treatment This is a expert opinion article on conservative interventions for radial tunnel syndrome (RTS). Unfortunately, I was unable to find a more recent paper on conservative interventions for RTS. I have excluded from this synopses modalities such as ultrasound treatment (US) described in the paper. The author's recommendation is based on animal studies showing improvements in nerve conduction (NC) following US. I am not however convinced about the clinical relevance of these findings, as changes in clients' symptoms are not always correlated with improvements in NC (see this synopsis ). If you are really interested in US modalities and the author's opinion on the topic, you can always read the paragraph yourself (page 186-187), it is a 5-10 minutes read. The other treatment approach, which has recently been shown to be effective in other entrapment neuropathies, includes radial/median nerve glides. In addition, a wrist splint may limit the amount of wrist flexion, which may otherwise contribute to nociception in mechanosensitive radial nerves. It was also suggested to do sensorimotor training (e.g. graphesthesia, mirror therapy) to address potential cortical remapping, which can be present in clients with entrapment neuropathies. Clinical Take Home Message : Currently there is very limited evidence supporting the use of any conservative intervention for radial tunnel syndrome (RTS), which is a mild entrapment neuropathy of the posterior interosseous nerve . This may be due to the extremely low incidence of this condition which affects 1 in 10,000 people . The current best approach is therefore based on indirect evidence from other entrapment neuropathies (e.g. carpal tunnel syndrome) and preclinical science. In particular, it appears that nerve glides may be helpful in reducing symptoms in RTS. In addition, the treatment of other potential compression points along the radial nerve, may be useful ( see this synopsis on carpal tunnel syndrome ). Finally, there appears to be preclinical evidence of a neuroprotective and neuroregenerative effect of mild to moderate aerobic exercise (e.g. walking, swimming, jogging) for peripheral entrapment neuropathies ( Jesson et al. 2020 - I will make a synopsis on this). Due to the very low incidence of RTS, other more common conditions such as cervical radiculopathy and lateral epicondylalgia should be excluded first. Open Access URL : https://www.jhandtherapy.org/article/S0894-1130(06)00060-3/fulltext Abstract Current best evidence for the conservative management of radial tunnel syndrome (RTS) consists primarily of expert opinion and inferences taken from studies on other nerve compressions and related syndromes. There are limited data reported in the literature of this particular disorder. This article reviews literature on modalities, therapeutic exercise, ergonomic interventions, and cortical reorganization, and how they may be considered for intervention with RTS. The author's preferred method of treatment, as based on theoretical constructs, for RTS is presented. Definitive evidence in the literature to support the conservative interventions suggested is lacking. Suggestions for clinical management and study are included in this therapist's clinical perspective.

Median and ulnar nerve anastomoses in the upper limb: A meta-analysis. Roy, J., Henry, B. M., PĘkala, P. A., Vikse, J., Saganiak, K., Walocha, J. A., & Tomaszewski, K. A. (2016) Level of Evidence : 1a Follow recommendation : 👍 👍 👍 👍 Type of study : Anatomical Topic : Median nerve variations - Relevance in carpal tunnel syndrome This is a systematic review and meta-analysis assessing the prevalence of median nerve variations in the forearm and hand. There were a total of 58 studies assessing 10,562 upper limbs (from cadavers and nerve conduction studies in living participants). All the studies were pooled in a prevalence meta-analysis. The three most common median nerve anatomical variations in the forearm were described and their prevalence reported (I excluded the Marinacci anastomosis as it is rare 0.7% of the population). These included Martin‐Gruber anastomosis (MGA), Riche‐Cannieu anastomosis (RCA), and Berrettini anastomosis (BA). The Martin‐Gruber anastomosis (MGA) is described as a communicating branch from the median nerve to ulnar nerve in the forearm. Through this anastomosis, the median nerve innervates the thenar eminence bypassing the carpal tunnel. The pooled prevalence of this anastomosis (which is mainly motor) has been shown to be 20% ( 95%CI : 16% to 23%). The Riche‐Cannieu anastomosis (RCA) is defined as a communicating branch from the ulnar nerve to the median nerve in the palm of the hand. Through this anastomosis the ulnar nerve innervates the thenar eminence muscles. The pooled prevalence of this anastomosis (which is motor) has been shown to be 60% ( 95%CI : 30% to 80%). Last but not least, Berrettini anastomosis (BA) is a sensory connection between median and ulnar nerve in the palm that innervate the middle and ring finger (digital nerves). Through this anastomosis, both the ulnar and median nerve provide sensory innervation to the ulnar aspect of the middle finger and radial aspect of the ring finger. The pooled prevalence of this anastomosis (which is sensory) has been shown to be 60% ( 95%CI : 40% to 80%). Clinical Take Home Message : Based on what we know today, at least three median nerve variations in the forearm and hand are common or normal in our clients. These variations may explain why a limited number of people presenting with severe carpal tunnel compression (significant numbness with or without pain) do not present with motor impairments in the thenar muscles (MGA and RCA anastomosis). In addition, sensory changes involving the middle and ring finger in clients with carpal tunnel syndrome may depend on the presence of communicating branches between median and ulnar nerve (BA anastomosis). This last anastomosis may explain why there is significant variance in the textbooks description of sensory changes associated with carpal tunnel syndrome (involvement or not of ring finger). URL : https://onlinelibrary.wiley.com/doi/epdf/10.1002/mus.24993 You can ask the authors for the full text through Research Gate . Available through EBSCO Health Databases for PNZ members. Abstract Introduction: The most frequently described anomalous neural connections between the median and ulnar nerves in the upper limb are: Martin‐Gruber anastomosis (MGA), Marinacci anastomosis (MA), Riche‐Cannieu anastomosis (RCA), and Berrettini anastomosis (BA). The reported prevalence rates and characteristics of these anastomoses vary significantly between studies. Methods: A search of electronic databases was performed to identify all eligible articles. Anatomical data regarding the anastomoses were pooled into a meta‐analysis using MetaXL 2.0. Results: A total of 58 (n = 10,562 upper limbs) articles were included in the meta‐analysis. The pooled prevalences were: MGA, 19.5% (95% confidence interval [CI], 16.2%–23.1%); MA, 0.7% (95% CI, 0.1%–1.7%); RCA, 55.5% (95% CI, 30.6%–79.1%); and BA, 60.9% (95% CI, 36.9%–82.6%). The results also showed that MGA was more commonly found unilaterally (66.8%), on the right side (15.7%), following an oblique course (84.8%), and originating from the anterior interosseous nerve with a prevalence of 57.6%. Conclusions: As anastomoses between the median and ulnar nerves occur commonly, detailed anatomical knowledge is essential for accurate interpretation of electrophysiological findings and reducing the risk of iatrogenic injuries during surgical procedures.

Why are assumptions passed off as established knowledge? Weisman, A., Quintner, J., Galbraith, M., & Masharawi, Y. (2020) Level of Evidence : 5 Follow recommendation : 👍 Type of study : Therapeutic Topic : Logical fallacies This article presents a discussion on logical fallacies in medicine. These fallacies apply to both expert opinions and published articles introducing new hypotheses rather than established theories. The following recommendations were made: - Avoid assuming that the achieved outcomes are the result of what preceded it (fallacy - post hoc ergo propter hoc). For example, you have given your clients "stabilisation" exercises for symptomatic 1st cmcj OA and their pain improved. You therefore assume that the issue is 1st cmcj instability when in fact pain may have improved with general thumb exercises. - Avoid assuming that incidental findings associated with a certain pathology are the cause of that pathology (e.g. repetitive strain injury, central sensitisation). For example, one of your clients is an athlete doing high exercise volume and you assume that the symptoms that they developed are due to repetitive strain injury. High loads and repetitive activities may not be the only cause of their pain and other factors such as poor sleep, fatigue, and mental health may be large contributing factors to their pain ( see this synopsis ). Clinical Take Home Message : This paper suggests keeping an open mind and challenging the concepts guiding our treatment approach, as well as the opinion of experts in the field. By assuming that we are wrong and logically test the potential alternatives (e.g. diagnostic, therapeutic) we can increase the likelihood of doing what is best for our patients. Challenging one's own practice is difficult and it has always been throughout history. URL : https://www.sciencedirect.com/science/article/abs/pii/S0306987720302437 Possibly available through EBSCO Health Databases for PNZ members. Abstract “What can be asserted without evidence can also be dismissed without evidence.” (Christopher Hitchens, 2007).

A randomized clinical trial comparing early active motion programs: Earlier hand function, TAM, and orthotic satisfaction with a relative motion extension program for zones V and VI extensor tendon repairs. Collocott, S. J. F., Kelly, E., Foster, M., Myhr, H., Wang, A., & Ellis, R. F. (2020) Level of Evidence : 1b Follow recommendation : 👍 👍 👍 👍 Type of study : Therapeutic Topic : RME - Zone V and VI extensor repair This is a randomised controlled trial assessing the effectiveness of controlled active motion (CAM) and relative motion extension (RME) splinting program following zone V and VI extensor tendon repair. Participants (N = 42) were included if they presented with a primary repair of maximum two digits in zone V and VI. Participants were excluded if they presented with additional injuries (e.g. fractures). Effectiveness of each intervention was assessed through the Sollerman Hand Function Test (SHFT - primary outcome), QuickDASH, total active motion (TAM), days to return to full work duties, grip strength, compliance with splinting regime, and participants' satisfaction (all secondary outcomes). The outcomes were measured at 4 and 8 weeks after surgery, except for grip strength, which was measured at 8 weeks only. Treatment allocation was randomised. The assessor was blinded to treatment allocation. Participants were provided with either a RME splint of the affected finger/s (n = 21) or CAM protocol (n = 21). The RME splint group was advised to wear the RME splint all day and a volar block at night. Advice was given to avoid composite flexion during the day. At 10 days, participants could return to work lifting a maximum of 5 kg. The splint was gradually weaned from week 4 post surgery (RME off for light tasks), and at week 6 participants used the RME for heavy tasks only without the need to wear a volar block at night. From week 8, any splint was to be discontinued. The RME group did not have to do any exercises unless they presented with range of movement limitations at week 4. The CAM splint group had to wear a volar block (except for pipj and dipj) during the day, which was reinforced at night (including pipj and dipj). In addition, they had to perform several exercises during the day. Return to work was similar to the RME splint group, although the CAM group was advised not to resume heavy duties at work until week 8 (two weeks later than CAM splint). The results showed that participants in the RME group recovered more quickly in terms of function (SHFT, QuickDASH) and TAM compared to the CAM group at 4 weeks. These results were both statistically and clinically significant. Overall, participants were more satisfied with the RME compared to the CAM approach. At 8 weeks TAM was still statistically and clinically significant greater in the RME splint group, however, function was no longer different between groups. No differences were noted in return to work, adherence, or complications between the two groups. Overall there was a 10% probability that these group differences were due to chance (10 group comparisons were performed, 5 of these were significant). Clinical Take Home Message : Based on what we know today, hand therapists may choose to use an RME over the CAM splinting program for extensor tendon repair in zone V and VI. The RME protocol provides greater improvement in function and finger range of movement at four weeks without the need to do a home exercise program. In addition, the number of complications (e.g. tendon rupture) was as low as in the CAM group, making the RME a safe protocol. URL : https://www.jhandtherapy.org/article/S0894-1130(18)30082-6/abstract Available through the Journal of Hand Therapy for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Study Design: Randomized clinical trial with parallel groups. Introduction: Early active mobilization programs are used after zones V and VI extensor tendon repairs; two programs used are relative motion extension (RME) orthosis and controlled active motion (CAM). Although no comparative studies exist, use of the RME orthosis has been reported to support earlier hand function. Purpose of the Study: This randomized clinical trial investigated whether patients managed with an RME program would recover hand function earlier postoperatively than those managed with a CAM program. Methods: Forty-two participants with zones V-VI extensor tendon repairs were randomized into either a CAM or RME program. The Sollerman Hand Function Test (SHFT) was the primary outcome measure of hand function. Days to return to work, QuickDASH (Disabilities of Arm, Shoulder and Hand) questionnaire, total active motion (TAM), grip strength, and patient satisfaction were the secondary measures of outcome. Results: The RME group demonstrated better results at four weeks for the SHFT score ( P  = .0073; 95% CI: −10.9, −1.8), QuickDASH score ( P  = .05; 95% CI: −0.05, 19.5), and TAM ( P  = .008; 95% CI: −65.4, −10.6). Days to return to work were similar between groups ( P  = .77; 95% CI: −28.1, 36.1). RME participants were more satisfied with the orthosis ( P  < .0001; 95% CI: 3.5, 8.4). No tendon ruptures occurred. Discussion: Participants managed using an RME program, and RME finger orthosis demonstrated significantly better early hand function, TAM, and orthosis satisfaction than those managed by the CAM program using a static wrist-hand-finger orthosis. This is likely due to the less restrictive design of the RME orthosis. Conclusions: The RME program supports safe earlier recovery of hand function and motion when compared to a CAM program following repair of zones V and VI extensor tendons.

Use of a relative motion flexion orthosis for postoperative management of zone I/II flexor digitorum profundus repair: A retrospective consecutive case series. Henry, S. L., & Howell, J. W. (2020) Level of Evidence : 4 Follow recommendation : 👍 👍 Type of study : Therapeutic Topic : RMF - Flexor tendon zone I and II This is a retrospective case series assessing the effectiveness of a relative motion flexion (RMF) splinting program following zone I and II flexor tendon repair. Participants (N = 10) were included if they presented with a single digit lesion in zone I and II. Surgical interventions included a four strand repair of flexor digitorum profundus (FDP) with pulley venting. Flexor digitorum superficialis (FDS) was not repaired if injured. The RMF splint placed the affected finger in 30°-40° of relative flexion compared to the other fingers. A wrist orthosis was utilised in combination with the RMF splint 24/7 for the first 3 weeks. After 3 weeks, the RMF was worn full time while the wrist splint was used at night and during at risk tasks (e.g. jogging) only. Lifting light objects with both hands was allowed at the three weeks mark. At six weeks, the RMF splint was still worn 24/7 and patients could lift a maximum of 3.5 kg. Use of the wrist splint was discontinued at this point. All restrictions, which included the use of the RMF splint, were lifted between week 8 and 10. Effectiveness of the intervention was assessed through ipj range of movement (total active range of movement - %TAM), grip strength, and rupture rate. The results showed that 4 participants had an excellent, 1 had a good, and 3 had a fair range of movement at the end of the rehabilitation (% of contralateral TAM outcome). Grip strength ranged from 63% to 100% of the contralateral. No ruptures were reported. Clinical Take Home Message : In the future, a RMF splint in combination with a wrist splint may be an alternative to more traditional flexor tendon repair in zone I and II when only one digit is involved. There is however not enough high quality research (at this point in time) to allow the implementation of this approach according to an evidence based approach. The risk of tendon ruptures has not been formally assessed through randomised controlled trials and there is a possibility of it being higher than the currently adopted protocols. URL : https://www.jhandtherapy.org/article/S0894-1130(18)30389-2/fulltext Available through the Journal of Hand Therapy for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Study Design: A retrospective, single-center, consecutive case series. Introduction: In concept, a relative motion flexion (RMF) orthosis will induce a “quadriga effect” on a given flexor digitorum profundus (FDP) tendon, limiting its excursion and force of flexion while still permitting a wide range of finger motion. This effect can be exploited in the rehabilitation of zone I and II FDP repairs. Purpose of the Study: To describe the use of RMF orthoses to manage zone I and II FDP 4-strand repairs. Methods: Medical record review of 10 consecutive zone I and II FDP tendon repairs managed with RMF orthosis for 8 to 10 weeks in combination with a static dorsal blocking or wrist orthosis for the initial 3 weeks. Results: Indications included sharp lacerations (n = 6), ragged lacerations (n = 2), staged flexor tendon reconstruction (n = 1), and type IV avulsion (n = 1). In 8 of the 10 cases that completed follow-up, the mean arc of proximal interphalangeal/distal interphalangeal active motion were as follows: sharp, 0° to 106°/0° to 75°; ragged, 0° to 90°/0° to 25°; reconstruction, 0° to 90°/10° to 45°; and avulsion, 0° to 95°/0° to 20°. Grip performance available for 6 of 10 cases was 62% to 108% of the dominant hand. There were no tendon ruptures, secondary surgeries, or proximal interphalangeal joint contractures. Conclusion: Based on this small series, the RMF approach appears to be safe and effective. It can lead to similar mobility and functional recovery as other early active motion protocols, with certain practical advantages and without major complications. Further investigation with larger, multicenter, prospective, longitudinal cohorts and/or randomized clinical trials is necessary.

Proximal median nerve compression: Pronator syndrome. Adler, J. A., & Wolf, J. M. (2020) Level of Evidence : 5 Follow recommendation : 👍 Type of study : Diagnostic, Therapeutic Topic : Median nerve compression - Pronator teres syndrome This is a narrative review on pronator teres syndrome. Pronator teres syndrome presents clinically with paresthesias in the median nerve distribution distally to the pronator teres and pain in the volar aspect of the forearm. The differential diagnosis includes cervical radiculopathy, brachial neuritis, thoracic outlet syndrome, anterior interosseous nerve (AIN) syndrome, and carpal tunnel syndrome (CTS). Physical tests may be helpful in discriminating between pronator teres syndrome, AIN syndrome, and CTS when they are present in isolation. In particular, the AIN syndrome is associated with motor but no sensory changes in comparison to pronator teres and CTS syndrome. Pronator teres syndrome may be associated with thenar eminence numbness (palmar cutaneous branch of the median nerve branches before the carpal tunnel) while in CTS there should be no numbness in the thenar eminence. With AIN syndrome, weakness (if present) is usually localisted to FPL and FDP of the index and middle finger. In terms of special tests, Phalen's and Tinel's test should be negative if there is an isolated pronator teres syndrome. These two condition may however present in combination. Unfortunately, nerve conduction studies are not useful to assess pronator teres syndrome. Conservative treatment should always be trialled for 3 to 6 month before surgery. This may include rest NSAIDs, activity modification, and physical therapy. Clinical Take Home Message : Hand therapists may consider pronator teres syndrome diagnosis when clients present with pain in the forearm and numbness in the peripheral median nerve distribution. Differential diagnoses for this condition may include cervical radiculopathy, brachial neuritis, thoracic outlet syndrome, anterior interosseous nerve (AIN) syndrome, and carpal tunnel syndrome (CTS). A few tests are available to make a diagnosis of cervical radiculopathy, however, dermatomal patterns are not reliable. Brachial neuritis and thoracic outlet syndrome present with limited special tests available as a gold standard for their diagnosis does not exist (similar to pronator teres syndrome). AIN syndrome has no sensory impairments and may present with FPL, index and middle finger FDP weakness. Carpal tunnel syndrome easier to diagnose, with nerve conduction studies helpful in the identification of moderate to severe CTS. For more information on nerve conduction study impairments in CTS have a look at this synopsis . URL : https://www.sciencedirect.com/science/article/pii/S0363502320304019 Available through the Journal of Hand Surgery (American volume) for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Pronator syndrome (PS) is a compressive neuropathy of the median nerve in the proximal forearm, with symptoms that often overlap with carpal tunnel syndrome (CTS). Because electrodiagnostic studies are often negative in PS, making the correct diagnosis can be challenging. All patients should be initially managed with nonsurgical treatment, but surgical intervention has been shown to result in satisfactory outcomes. Several surgical techniques have been described, with most outcomes data based on retrospective case series. It is essential for clinicians to have a thorough understanding of median nerve anatomy, possible sites of compression, and characteristic clinical findings of PS to provide a reliable diagnosis and treat their patients.

Thumbs up: Imagined hand movements counteract the adverse effects of post-surgical hand immobilization. Gandola, M., Zapparoli, L., Saetta, G., De Santis, A., Zerbi, A., Banfi, G., . . . Paulesu, E. (2019) Level of Evidence : 3b Follow recommendation : 👍 👍 Type of study : Therapeutic Topic : Trapeziectomy - Motor imagery This is a prospective study assessing the outcomes of participants undergoing explicit motor imagery post trapeziectomy for first carpometacarpal joint (cmcj) OA. Explicit motor imagery simply means imagining to perform a movement without physically performing it. A total of 22 participants underwent motor imagery (n=12) or limited motor imagery training (n=10) during the immobilisation period (2 weeks) post trapeziectomy. The differentiation between the motor imagery vs limited motor imagery groups was the compliance with the program (no randomisation). In particular, the motor imagery group had an 84% compliance while the limited motor imagery group had a 20% compliance with the program. Outcomes included were pain during thumb movement (VAS -thumb opposition, flexion, and circumduction) and disability (DASH). These outcomes were measured after 2 weeks immobilisation. The motor imagery task involved two daily sessions (AM and PM) during which participants had to imagine performing thumb opposition, flexion, and circumduction. The results showed that there was no statistically significant difference between groups in function (DASH). Pain improved to a statistically and clinically significant level in the motor imagery group (2.3 points improvement out of 10) during thumb circumduction movement, with a large between groups difference (4 points out of 10). There were no differences between groups for pain with thumb flexion and opposition. Overall, there is a low risk that these differences are due to chance as corrections for multiple statistical tests were completed. Clinical Take Home Message : Based on what we know today, motor imagery imagery may be useful for clients undergoing a period of immobilisation following trapeziectomy. This intervention does not appear to improve function, although it reduces significantly the pain on movement that clients experience when coming out of the cast. If interested, clinicians can download the Orientate app (It's free) and ask clients to imagine replicating the hand position shown on the app. Open access URL : https://www.sciencedirect.com/science/article/pii/S2213158219301883 Abstract Motor imagery (M.I.) training has been widely used to enhance motor behavior. To characterize the neural foundations of its rehabilitative effects in a pathological population we studied twenty-two patients with rhizarthrosis, a chronic degenerative articular disease in which thumb-to-fingers opposition becomes difficult due to increasing pain while the brain is typically intact. Before and after surgery, patients underwent behavioral tests to measure pain and motor performance and fMRI measurements of brain motor activity. After surgery, the affected hand was immobilized, and patients were enrolled in a M.I. training. The sample was split in those who had a high compliance with the program of scheduled exercises (T+, average compliance: 84%) and those with low compliance (T−, average compliance: 20%; cut-off point: 55%). We found that more intense M.I. training counteracts the adverse effects of immobilization reducing pain and expediting motor recovery. fMRI data from the post-surgery session showed that T+ patients had decreased brain activation in the premotor cortex and the supplementary motor area (SMA); meanwhile, for the same movements, the T− patients exhibited a reversed pattern. Furthermore, in the post-surgery fMRI session, pain intensity was correlated with activity in the ipsilateral precentral gyrus and, notably, in the insular cortex, a node of the pain matrix. These findings indicate that the motor simulations of M.I. have a facilitative effect on recovery by cortical plasticity mechanisms and optimization of motor control, thereby establishing the rationale for incorporating the systematic use of M.I. into standard rehabilitation for the management of post-immobilization syndromes characteristic of hand surgery.

The effects of resistance training on muscle strength, joint pain, and hand function in individuals with hand osteoarthritis: a systematic review and meta-analysis. Magni, N. E., McNair, P. J., & Rice, D. A. (2017) Level of Evidence : 1a- Follow recommendation : 👍 👍 👍 👍 Type of study : Therapeutic Topic : Resistance training - application in hand OA This is a systematic review and meta-analysis assessing the effectiveness of resistance training exercises for hand OA. Five RCTs were included in the systematic review, for a total of 350 participants. All the studies were included in the meta-analysis and they were assessed through the Risk of Bias criteria recommended by the Cochrane Review Group. The overall strength of evidence was assessed through the GRADE approach ("low", "very low", "moderate", "high"), which has also been suggested by the Cochrane group for systematic reviews. Resistance training exercises were compared to control groups undergoing no exercise. Efficacy of intervention was assessed through improvements in grip strength, function (e.g. FIHOA, AUSCAN), and pain (e.g. NRS, AUSCAN pain). The assessment time points varied significantly, and they ranged from 6 to 24 weeks. Moderate quality evidence showed that resistance training did not improve grip strength to a statistically or clinically significant level (8% difference between groups in favor of resistance training). Low quality evidence showed no effect of resistance training on function, and a small, non clinically significant, effect on pain relief (0.5 out of 10 points improvement in favor of resistance training). Overall, due to multitude of statistical tests performed (3 tests) and the number of significant findings (1 test) there is a 15% probability that the results are just due to chance. Clinical Take Home Message : Based on what we know today, resistance training interventions do not appear to have a clinically relevant effect in clients with hand OA. They do not appear to improve grip strength, function, nor joint pain. Considering these results, a multimodal approach to the treatment of hand OA may be more effective (see previous synopsis on the topic). Open access URL : https://arthritis-research.biomedcentral.com/articles/10.1186/s13075-017-1348-3 Abstract Background: Hand osteoarthritis is a common condition characterised by joint pain and muscle weakness. These factors are thought to contribute to ongoing disability. Some evidence exists that resistance training decreases pain, improves muscle strength, and enhances function in people with knee and hip osteoarthritis. However, there is currently a lack of consensus regarding its effectiveness in people with hand osteoarthritis. Therefore, the aim of this systematic review and meta-analysis was to establish whether resistance training in people with hand osteoarthritis increases grip strength, decreases joint pain, and improves hand function. Methods: Seven databases were searched from 1975 until July 1, 2016. Randomised controlled trials were included. The Cochrane Risk of Bias Tool was used to assess studies' methodological quality. The Grade of Recommendations Assessment, Development, and Evaluation system was adopted to rate overall quality of evidence. Suitable studies were pooled using a random-effects meta-analysis. Results: Five studies were included with a total of 350 participants. The majority of the training programs did not meet recommended intensity, frequency, or progression criteria for muscle strengthening. There was moderate-quality evidence that resistance training does not improve grip strength (mean difference = 1.35; 95% confidence interval (CI) = -0.84, 3.54; I 2 = 50%; p = 0.23 ). Low-quality evidence showed significant improvements in joint pain (standardised mean difference (SMD) = -0.23; 95% CI = -0.42, -0.04; I 2 = 0%; p = 0.02) which were not clinically relevant. Low-quality evidence demonstrated no improvements in hand function following resistance training (SMD = -0.1; 95% CI = -0.33, 0.13; I 2 = 28%; p = 0.39). Conclusion: There is no evidence that resistance training has a significant effect on grip strength or hand function in people with hand osteoarthritis. Low-quality evidence suggests it has a small, clinically unimportant pain-relieving effect. Future studies should investigate resistance training regimes with adequate intensity, frequency, and progressions to achieve gains in muscle strength.

An exploratory investigation into the longevity of pain reduction following multisensory illusions designed to alter body perception. Barnard, A., Jansen, V., Swindells, M., Arundell, M., & Burke, F. (2020) Level of Evidence : 4 Follow recommendation : 👍 👍 Type of study : Therapeutic Topic : Hand osteoarthritis - Illusory resizing This is a case-series study assessing the effectiveness of illusory sensory resizing of the hand on pain in participants with hand osteoarthritis (OA). Participants (N = 38) were diagnosed with hand OA through clinical criteria. The illusory visual resizing was achieved through cameras and screens which the participants looked at. The visual resizing could either give the illusion of stretching or shrinking the hand. This visual illusion was coupled with either a gentle traction (for the stretching illusion) or compression (for the shrinking illusion) of the most painful finger to boost the illusion effect. Pain was assessed on a Numerical Rating Scale (NRS) immediately before and after the intervention. The intervention provided participants with an illusory sensory resizing (visual and traction/compression) lasting two minutes. Participants were also asked to report how long pain-relief lasted after the illusory resizing. The choice of which illusion (shrinking vs stretching) to utilise, was based on a baseline test identifying which provided the most pain relief. Out of 38 participants, 28 (74%) reported pain relief with one of the illusions. Of these 28 participants, 17 (60%) reported improvement with the stretching illusion and 11 (40%) with the shrinking illusion. The results showed that after two minutes of illusory resizing, the stretching illlusion improved pain by 1.5 points out of 10, and the shrinking illusion improved pain by 0.5 out of 10 points (difference between medians provided). The effect of the intervention lasted for four minutes in 16% of participants, 20 minutes in 68% of participants, and between 7 hours and 10 weeks in 16% of participants. There was no statistical difference between the two illusions on pain. Clinical Take Home Message : Hand therapists may trial imagery resizing coupled with gentle traction or compression of the most painful finger in people with hand OA. This intervention, may provide immediate small and short lasting pain relieving effects in people with hand OA. This regime may be trialled in patients that are unable to undergo other interventions supported by higher quality evidence (e.g. NSAIDs). URL : https://www.mskscienceandpractice.com/article/S2468-7812(19)30119-5/pdf

Radial tunnel syndrome: definition, distinction and treatments. Bo Tang, J. (2020) Level of Evidence : 5 Follow recommendation : 👍 Type of study : Diagnostic, Therapeutic Topic : Posterior interosseous nerve entrapment - Radial tunnel syndrome vs PIN syndrome This is a narrative review on radial tunnel syndrome (RTS) and posterior interosseous nerve syndrome (PINS). These two presentations are both entrapment neuropathies of the posterior interosseous nerve, however, RTS is a mild entrapment neuropathy while PIN is a severe entrapment neuropathy (similar to mild vs severe carpal tunnel syndrome). The clinical presentations of RTS and PINS are different. RTS presents with pain in the lateral aspect of forearm 4-5 cm distal from the lateral epicondyle. PINS presents with no pain but with palsy of the wrist, finger, and thumb extensors, except for extensor carpi radialis longus. Clients with PINS will therefore present with painless weak wrist extension associated with radial deviation. Investigations for people with RTS or PINS may include x-rays and US, which will be able to exclude the presence of radiocapitellar joint osteoarthritis or space invading lesions which may be responsible for the entrapment. The differential diagnosis includes lateral epicondylalgia, cervical radiculopathy, high radial nerve palsy (e.g. Saturday night palsy), and extensive tendon ruptures of the extensors compartment. If a diagnosis of RTS is made, conservative treatment should be trialed for at least 6 months before surgery is considered. Overall, entrapment of the posterior interosseous nerve, especially severe entrapment, appears to be rare compared to median and ulnar nerve entrapment neuropathies (e.g. carpal tunnel syndrome, cubital tunnel syndrome). Clinical Take Home Message : A mild (RTS) or severe (PINS) entrapment neuropathy of the posterior interosseous nerve is rare. A mild entrapment neuropathy (RTS) usually presents with pain 4-5 cm distal to the lateral epicondyle. A severe entrapment neuropathy (PINS) presents with no forearm pain but significant motor weakness of the extensors compartment of the forearm. The key characteristic discriminating PINS from a higher nerve palsy (e.g. Saturday night palsy) or cervical radiculopathy with motor impairments, is that PINS will present with weak wrist extension associated with radial deviation (ECRL is intact). In addition, cervical radiculopathies present with neck pain in 80% of cases and often present with pain above the elbow . When differentiating between RTS and lateral epicondylalgia, the location of pain is the most useful indicator, with lateral epicondylalgia presenting with more proximal symptoms. URL : https://journals.sagepub.com/doi/10.1177/1753193420953990 Available through EBSCO Health Databases for PNZ members. Abstract Radial tunnel syndrome (RTS) is a disease causing lateral elbow and proximal dorsolateral forearm pain that may radiate to the wrist and dorsum of the fingers without obvious extensor muscle weakness. An epidemiological study shows an incidence of nine new cases of radial neuropathy per 100,000 population for men and six per 100,000 for women in a 10-year period (Hulkkonen et al., 2020). These incidences are far less than entrapments of the median and ulnar nerves. There are ambiguous descriptions of RTS in relation to posterior interosseous nerve (PIN) compression. This article intends to discuss the anatomy of the radial tunnel and the clinical distinctions between two entities.

Does diabetes mellitus change the carpal tunnel release outcomes? Evidence from a systematic review and meta-analysis. Moradi, A., Sadr, A., Ebrahimzadeh, M. H., Hassankhani, G. G., & Mehrad-Majd, H. (2020) Level of Evidence : 1a Follow recommendation : 👍 👍 👍 👍 Type of study : Therapeutic Topic : Surgical decompression of the carpal tunnel - Outcomes in diabetic vs healthy clients This is a systematic review and meta-analysis assessing outcomes in participants with and without diabetes following surgical decompression of the carpal tunnel. Ten studies were included for a total of 2,869 participants. Of these participants, 2423 were healthy and 446 presented with diabetes. Seventy percent of these participants were females. On average, participants were 56 years old. Outcomes included function, sensory, and motor nerve conduction studies. The results showed that there were no functional differences between clients with or without diabetes. Sensory nerve conduction improved to a greater extent in the healthy compared to diabetic participants. However, considering the multiple statistical tests undertaken, 23% of the results are due to chance. This reduces our confidence in these findings, especially considering that these differences did not have clinical repercussions in terms of function. Clinical Take Home Message : Hand therapists may reassure clients that diabetes does not appear to affect the results of surgery for carpal tunnel syndrome. However, hand therapists should remember that depression and mental health do affect post surgical satisfaction and the amount of health care resources required following carpal tunnel decompression. URL : https://www.sciencedirect.com/science/article/pii/S0894113020300235 Available through the Journal of Hand Therapy for HTNZ members. Available through EBSCO Health Databases for PNZ members. Abstract Study Design: A systematic review and meta-analysis. Introduction: Carpal tunnel syndrome (CTS) is one of the most common upper extremity conditions which mostly affect women. Management of patients suffering from both CTS and diabetes mellitus (DM) is challenging, and it was suggested that DM might affect the diagnosis as well as the outcome of surgical treatment. Purpose of the Study: This meta-analysis was aimed to compare the response with CTS surgical treatment in diabetic and nondiabetic patients. Methods: Electronic databases were searched to identify eligible studies comparing the symptomatic, functional, and neurophysiological outcomes between diabetic and nondiabetic patients with CTS. Pooled MDs with 95% CIs were applied to assess the level of outcome improvements. Results: Ten articles with 2869 subjects were included. The sensory conduction velocities in the wrist-palm and wrist–middle finger segments showed a significantly better improvement in nondiabetic compared with diabetic patients (MD = −4.31, 95% CI = −5.89 to −2.74, P  < .001 and MD = −2.74, 95% CI = −5.32 to −0.16, P  = .037, respectively). However, no significant differences were found for the improvement of symptoms severity and functional status based on the Boston Carpal Tunnel Questionnaire and Quick Disabilities of the Arm, Shoulder, and Hand questionnaire as well as motor conduction velocities and distal motor latencies. Conclusion: Metaresults revealed no significant difference in improvements of all various outcomes except sensory conduction velocities after CTS surgery between diabetic and nondiabetic patients. A better diabetic neuropathy care is recommended to achieve better sensory recovery after CTS surgery in diabetic patients.